Features June 2014 Issue

The Complicated Nature of Arthritis

Having arthritis in addition to other chronic diseases is more the rule than exception; Cleveland Clinic’s multidisciplinary approach offers solutions.

Arthritis is known to go hand in hand with stiff, swollen and painful joints. But did you know that when the condition is diagnosed most people might already be living with the impact of more than one chronic disease?

A diagnosis of inflammatory arthritis requires specialized care to monitor other potential chronic conditions, including cardiovascular disease.

While the implications of arthritis as a multi-system disease are becoming more understood, a recent study published in Family Practice (Dec. 2013) found that at the onset of inflammatory arthritis, nearly three-quarters of the 3,354 patients reviewed had at least one other chronic disease.
The research also showed that it was quite common for the participants to have more than one chronic disease, and 5 percent had six or more chronic diseases. Among those that top the list are cardiovascular disease, neurological disease and disease of the musculoskeletal and respiratory systems.

Beyond bones and joints
In order to provide the best care for the patient as a whole, it’s necessary to look beyond the obvious physical impact of arthritis, according to Cleveland Clinic rheumatologist Apostolos Kontzias, MD.

“We don’t see arthritis patients solely from a musculoskeletal standpoint. We have to take into account that the patient may have multiple conditions and that these may cause additional constraints on their health,” says Dr. Kontzias. “To provide the best overall care, it’s important that a variety of specialties are consulted for proper diagnosis and treatment.”

Expecting the unexpected
Acknowledging the complexity of arthritis patients is not a new concept for the staff at Cleveland Clinic’s Arthritis & Musculoskeletal Center. Launched over four years ago, the multidisciplinary clinic combines the expertise of rheumatologists, non-operative orthopaedist physicians, physiatrists, musculoskeletal radiologists, physical and occupational therapists, orthotic specialists, in addition to orthopaedic surgeons.

With each specialist seeing up to 20 patients daily, the unexpected complications of arthritis are anticipated. To explain, Dr. Kontzias tells how a known case of rheumatoid arthritis (RA) affecting the hand was actually more complex.

“A patient with RA referred to our center was unable to move her hand, and the pain was progressively worsening,” says Dr. Kontzias. “Upon clinical exam, I was able to determine that the pain was caused by a ruptured tendon in her hand due to sustained inflammation. The patient was seen that day by one of our orthopaedic surgeons who scheduled a timely procedure to repair the tendon. The patient was also given additional recommendations for optimized RA treatment to alleviate overall pain.

“By all of our specialists physically sharing the same space within the center, we’re able to access care from multiple specialties in one day if need be,” he says.
Identifying potential alternative sources of pain is a daily function for physical medicine and rehabilitation specialist Michael Schaefer, MD. For instance, what originally presented as a painful hip joint due to a total hip replacement actually had nothing to do with the hip, he says.

“By completing a diagnostic ultrasound-guided injection and reviewing her spine MRI from a previous facility, I determined that the hip pain was actually caused by a lumbar disc herniation,” Dr. Schaefer says. “We were able to refer her for proper spine care to relieve the pain.”

Signals of systemic involvement
While patients with forms of inflammatory arthritis may be thinking only of ways to gain pain relief, they should understand the underlying potential of the condition on their body overall, according to Dr. Schaefer.

"A case that required multiple layers of care was seen in a patient treated for arthritis who had undergone hip replacements and eventually would need knee replacement,” explains Dr. Schaefer. “I was managing knee pain with injections, but she suddenly developed severe diffuse joint and muscle pain throughout her body.”
After seeing the patient for an urgent same-day appointment, and consulting with one of the center’s rheumatologists, Dr. Schaefer was able to determine that the patient had developed reactive arthritis due to a possible infection from gastrointestinal bacteria salmonella. While reactive salmonella arthritis is uncommon, it can cause a debilitating group of symptoms, including joint pain and eye inflammation.

“That same day, the patient was seen by one of our rheumatologists who immediately began a course of steroids and advised on future lab testing needed for ongoing care,” he says. “We were able to improve her severe, debilitating pain in just a day or two.”

Anticipating additional needs
While cardiovascular disease complications are common in those with inflammatory arthritis, the research in Family Practice indicates additional chronic co-morbidities, including endocrine disease, psychological disease and digestive disorders.

“We can make recommendations specific to their particular disease, but at the same time we take into account any additional needs, including orthotics or an evaluation from our physical therapy department,” Dr. Kontzias explains. “Our multidisciplinary approach improves access in terms of immediate needs of our patients.”

“The center functions very well for complicated patients who may have combined problems including musculoskeletal, immunologic, neurological, and medical concerns,” Dr. Schaefer says. “We feel like we’re solving many puzzles each day.”